Functional Health Pattern

&
Nursing Care Plan
Submitted to:
Mr. Peter Orlino, RN

Submitted by:
Chezka Mae Carreon
Francis Adrian Palalon

January 11, 2017

Date
 DEMOGRAPHIC DATA
Name: F. O. A.

Birthdate: February 8, 1988

Age: 28 y/o

Nationality: Filipino

Civil Status: Single

Date Admitted: January 8, 2017, 10:58AM

Chief Complaint: A few hours PTA, patient experienced motor vehicular accident which fractured the left lower extremity, abrasion at right lower extremity and lacerated

wound at facial area. Glasgow coma scale is 14.

HPI:
A few hours PTA, patient experienced motor vehicular accident which fractured the left lower extremity, abrasion at right lower extremity and lacerated wound at facial
area. Glasgow coma scale is 14. Avulsed wound outer cantus of left eye near zygomatic bone (+) periorbital edema. (+) confluent abrasions on the periumbilical area.

General Impression:
Received patient lying in bed with D5LR 900ml hooked in the right metacarpal vein regulated at 10 gtts/min. Patient is well-groomed and awake and oriented to time
and place. Able to respond questions asked but not comprehensively.

Final Diagnosis: Fractured lower extremity, multiple abrasion, lacerated secondary to V.A.
 Cues Nursing Diagnoses Planning Interventions Rationale Evaluation
Subjective: Pain related to At the end of two days Monitor vital signs. - To obtain baseline At the end of 2 days
Sakit kaayo akong tiil movement of bone nursing interventions, data. nursing intervention the
unya gangulngol, ug ako fragments, edema, and the patient will be able goal was partially met as
pong nawong, as injury to the soft tissue to: Maintain immobilization - Relieves pain and evidenced by;
verbalized by the of affected part by prevents bone
patient. - verbalize relief of pain means of bed rest, cast, displacement and - displaying relaxed
splint, traction. extension of tissue manner; able to
- display relaxed injury. participate in activities,
Objective: manner; able to sleep/rest appropriately
- pain scale 5/10 participate in activities, Elevate and support - Promotes venous
- complete bed rest sleep/rest appropriately injured extremity. return, decreases - demonstrating use of
- facial mask edema, and may reduce relaxation skills and
- restlessness - demonstrate use of pain. diversional activities as
- irritability relaxation skills and indicated for individual
- self-focusing diversional activities as Evaluate and document - Influences situation
indicated for individual reports of pain or effectiveness of
situation discomfort, noting interventions. Many
location and factors, including level of
characteristics, including anxiety, may affect
intensity (010 scale), perception of pain.
relieving and aggravating
factors.

Encourage patient to - Helps alleviate anxiety.

discuss problems related Patient may feel need to
to injury. relive the accident
experience.
Explain procedures - Allows patient to
before beginning them. prepare mentally for
activity and to
participate in controlling
level of discomfort.

Provide alternative - Improves general

comfort measures circulation; reduces
(massage, backrub, areas of local pressure
position changes). and muscle fatigue.

Investigate any reports - May signal developing

of unusual or sudden complications (infection,
pain or deep, tissue ischemia,
progressive, and poorly compartmental
localized pain unrelieved syndrome).
by analgesics.
 Cues Nursing Diagnoses Planning Interventions Rationale Evaluation
Subjective: Activity intolerance At the end of two days Monitor blood pressure - Postural hypotension is At the end of 2 days
Di siya ka pasagad ug related to nursing interventions, (BP) with resumption of a common problem nursing intervention the
lihok-lihok ky tungod neuromuscular skeletal the patient will be able activity. Note reports of following prolonged bed goal was partially met as
anang iyang till, as impairment as to: dizziness. rest and may require evidenced by;
verbalized by the evidenced by decreased specific interventions
patient. muscle strength/control - regain/maintain - maintaining position of
mobility at the highest Encourage patient or - Increases blood flow to function
possible level assist with active and muscles and bone to
Objective: passive ROM exercises of improve muscle tone, - increasing
- pallor - maintain position of affected and unaffected maintain joint mobility; strength/function of
- restlessness function extremities. prevent contractures or affected and
- pain atrophy and calcium compensatory body
- fatigue - increase resorption from disuse parts
strength/function of
affected and Place in supine position - Reduces risk of flexion - demonstrating
compensatory body periodically if possible, contracture of hip. techniques that enable
parts when traction is used to resumption of activities
stabilize lower limb
- demonstrate fractures.
techniques that enable
resumption of activities Assist with self-care - Improves muscle
activities (such as strength and circulation,
bathing). enhances patient control
in situation, and
promotes self-directed
wellness.

- Encourage increased - Keeps the body well

fluid intake to 2000 hydrated, decreasing risk
3000 mL per day (within of urinary infection,
cardiac tolerance). stone formation, and
constipation.

Increase the amount of - Adding bulk to stool

roughage or fiber in the helps prevent
diet. Limit gas-forming constipation. Gas-
foods. forming foods may cause
abdominal distension,
especially in presence of
decreased intestinal
motility.

Initiate bowel program - Done to promote

(stool softeners, regular bowel
enemas, laxatives) as evacuation.
indicated.
 Cues Nursing Diagnoses Planning Interventions Rationale Evaluation
Subjective: Deficient knowledge At the end of two days Determine clients - Individual may not be At the end of 2 days
Nakalimot mn ko unsa related to lack of nursing interventions, ability, readiness, and physically, emotionally, nursing intervention the
toy gipang ingun sa exposure/recall as the patient will be able barriers to learning. or mentally capable at goal was met as
doctor, as verbalized by evidenced by to: this time. evidenced by;
the SO. questions/request for
information, statement - participate in learning Elevate the extremity as - Swelling and edema - participating in learning
of misconception process needed. tend to occur after cast process
Objective: removal.
- inaccurate follow- - verbalize - verbalizing
through of instructions understanding of Discuss dietary needs. - A low-fat diet with understanding of
- slightly hostile condition, prognosis, adequate quality protein condition, prognosis,
- apathetic and potential and rich in calcium and potential
complications promotes healing and complications
general well-being.
- correctly perform - correctly performing
necessary procedures List activities patient can - Organizes activities necessary procedures
and explain reasons for perform independently around need and who is and explain reasons for
actions and those that require available to provide actions
assistance. help.

Encourage patient to - Prevents joint stiffness,

continue active exercises contractures, and
for the joints above and muscle wasting,
below the fracture. promoting earlier return
to independence in
activities of daily living
(ADLs).

Instruct patient to - Reduces stiffness and

continue exercises as improves strength and
permitted. function of affected
extremity.

Inform patient that - Muscle strength will be

muscles may appear reduced and new or
flabby and atrophied different aches and pains
(less muscle mass). may occur for awhile
secondary to loss of
support.
 USUAL INITIAL (1-10-16) ONGOING (1-11-16) ONGOING (1-12-16)

I. HEALTH-PERCEPTION
HEALTH-MANAGEMENT PATTERN

- Patients health for the past 3 - Patient complains pain in a scale of - Patient complains pain in a scale - Patient complains pain in a
months is good as verbalized by the 5 out of 10. of 5 out of 10. scale of 5 out of 10.
patient with the SO.
Vital signs taken: Vital signs taken: Vital signs taken:
T: 36.3 C T: 36.5 C T: 36.5 C
- eats nutritious foods and water to P: 79 bpm P: 80 bpm P: 80 bpm
improve health RR: 21 cpm RR: 21 cpm RR: 21 cpm
BP: 110/80 mmHg BP: 110/80 mmHg BP: 110/80 mmHg

- complete immunizations Medication prescribed: - Continue medication as - Continue medication as

-Tranexamic Acid prescribed. prescribed.
-Renatidine
- no previous hospitalizations -Ampicillin

- does not anticipate problems caring

for himself.

II. NUTRITIONAL-METABOLIC
PATTERN

- patient usually eat vegetables, fish, - Patient is NPO since admission and - Patient was able to eat soft foods - Patient was able to eat soft
and in breakfast, lunch, or dinner until today. according to the Doctors order. foods according to the Doctors
- Patient drank 2 spoons of water only - He hardly opens his mouth widely. order.
-patient eats a lot of rice about 2 for today. -Complaining for pain in his mouth as - He still hardly opens his mouth
cups - He is complaining about his mouth verbalized by the SO. widely due to swelling
because he cannot really open it due -Complaining for pain in his
- did not experience indigestion, to swelling as verbalized by the SO. mouth as verbalized by the SO.
nausea or vomiting - No other complains.

- no food restrictions or allergies

- patients not taking any food

supplements

- no problems in ability to eat

III. ELIMINATION PATTERN

Bladder
- no problems or complaints with the
usual pattern of urinating Bladder Bladder Bladder
- He urinates 4 times today; the color - He urinates 2 times today; the - He urinates 2 times today; the
- usually urinates 4-5 times a day is yellowish. color is yellowish. color is yellowish.
- No assistive devices used. - No assistive devices used. - No assistive devices used.
- no assistive devices used

Bowel Bowel Bowel Bowel

- usually moves bowel during night - Have not yet defecated since - Have not yet defecated since - Have not yet defecated since
time with brownish in color and not admission. admission. admission.
watery - No assistive devices used. - No assistive devices used. - No assistive devices used.

- no assistive devices used

Skin Skin Skin
Skin - Upon assessment patients skin has - Upon assessment patients skin - Upon assessment patients
- patients skin condition: presence of abrasions in his left lower has presence of abrasions in his skin has presence of abrasions
 > light-brown extremities and presence of swelling left lower extremities and in his left lower extremities and
> warm to touch in his left side face. presence of swelling in his left side presence of swelling in his left
> normal skin turgor face. side face.
> absence of any edemas or lesions

IV. ACTIVITY-EXERCISE PATTERN

- patient is currently working at Solid - Patient is immobile because of his - Patient is immobile because of - Patient is immobile because
Ace Construction as maintenance. fracture. his fracture. of his fracture.

- no limitations in ability to ambulate, - Patient needs assistance. - Patient needs assistance. - Patient needs assistance.
dress, toileting, or bathing self
- Complains for pain. - Complains for pain. - Complains for pain.
- no complaints in dyspnea or fatigue

V. SLEEP-REST PATTERN

- patient usually sleeps around 10PM - Patient cannot sleep well because - Patient cannot sleep well - Patient cannot sleep well
to 5AM he complains for pain in his face and because he complains for pain in because he complains for pain
feet. his face and feet. in his face and feet.
- 7-8 hours of sleep at night
- No sleeping aids used. - No sleeping aids used. - No sleeping aids used.
- no sleeping aids used or any
medications or foods - Has an inadequate sleep. - Has an inadequate sleep - Has an inadequate sleep

- no difficulties in sleeping
VI. COGNITIVE-PERCEPTION
PATTERN

- no deficits in sensory perception

(hearing, sight, or touch) - Patient cannot open his left eye due - Patient cannot open his left eye - Patient cannot open his left
of bruise. due of bruise. eye due of bruise.
- does not wear eyeglasses or any
hearing aids - Patient barely speaks. - Patient barely speaks. - Patient barely speaks.

- no complaints of vertigo or
insensitivity to superficial pain or
cold/heat

- patients able to read and write

VII. SELF-PERCEPTION PATTERN

- patients is concerned of his own - Patient wants to be operated as - Patient wants to be operated as - Patient wants to be operated
health soon as possible as verbalized by the soon as possible as verbalized by as soon as possible as
patient. the patient. verbalized by the patient.
- describes himself as a hardworking
person

VIII. ROLE-RELATIONSHIP
PATTERN

Communication Communication Communication Communication

- patient speaks Cebuano - Patient speaks barely. - Patient speaks barely. - Patient speaks barely.
-Speech is not too clear. -Speech is not too clear. -Speech is not too clear.
- speech is clear and relevant

- able to express self verbally

Relationships Relationships Relationships Relationships

- patients parents speaks Cebuano. - Patient is together with his live-in - Patient is together with his live-in - Patient is together with his
partner. partner. live-in partner.
- patient lives with his live-in partner - His live-in was the only one who is - His live-in was the only one who - His live-in was the only one
and her child. taking care with him right now. is taking care with him right now. who is taking care with him
right now.
- turns to relatives or siblings in times
of need

- no signs of any type of abuse

(physical, verbal, substance)

IX. SEXUALITY-SEXUAL PATTERN

- Patient does not yet anticipate a - Patient does not yet anticipate a - Patient does not yet
- patient does not yet anticipate a change in his sexual relations. change in his sexual relations. anticipate a change in his
change in his sexual relations - Patient is not married but he has a - Patient is not married but he has sexual relations.
- patient is not married but he has a live-in partner and one child already. a live-in partner and one child - Patient is not married but he
live-in partner and one child already. already. has a live-in partner and one
child already.
X. COPING-STRESS
MANAGEMENT PATTERN

- patient usually makes his own - Patient and his live-in partner was - Patient and his live-in partner - Patient and his live-in partner
decisions the one who makes decisions. was the one who makes was the one who makes
- Patient was worried about on his decisions. decisions.
- no loss in life for the past year condition right now. - Patient was worried about on his - Patient was worried about on
condition right now. his condition right now.
- patient likes about himself as
hardworking

- does not have anything to change in

his life

- when patient is under stress or any

problems he seeks help from his live-
in partner.

XI. VALUE-BELIEF PATTERN

- patient is Roman Catholic

- patient finds source of strength and - Patient is Roman catholic. - Patient is Roman catholic. - Patient is Roman catholic.
meaning from God - Patient is praying for his fast - Patient is praying for his fast - Patient is praying for his fast
- verbalizes that God is very important recovery of his condition. recovery of his condition. recovery of his condition.
to his life
- seldom goes to church in Sunday
- no religious practices or rituals were
observed